SOURCE LIST APPLICATION TO: (Enter Name & Address of Exchange Purchasing Activity) DATE

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SOURCE LIST APPLICATION TO: (Enter Name & Address of Exchange Purchasing Activity) DATE ARMY & AIR FORCE EXCHANGE SERVICE SOURCE LIST APPLICATION TO: (enter name & address of Exchange purchasing activity) DATE INITIAL APPLICATION REVISED APPLICATION SECTION I - GENERAL This is an application to be added to the Exchange source file to provide the merchandise, food, supplies, equipment, services or construction indicated herein. Send an application to all Exchange activities where you desire to be included in the source file. The application must be signed by an officer of your firm. If you fail to respond to solicitations or presolicitation notices it will be understood by the Exchange to indicate lack of interest and concurrence in the removal of your name from the source files for the items/services concerned. SECTION II - SOURCE FILE DATA FIRM NAME & ADDRESS (enter complete address, including PERSON(S) AUTHORIZED TO COMMIT YOUR FIRM CONTRACTUALLY zip code, actual street address preferred) NAME TITLE EMAIL a. b. c. E-MAIL: (required) TIN NO. DUNS NO. TELEPHONE NO. FAX NO. TYPE OF ORGANIZATION TYPE OF BUSINESS INDIVIDUAL MANUFACTURER OR PRODUCER ADDRESS TO WHICH SOLICITATIONS ARE TO BE MAILED (If different from above) PARTNERSHIP REGULAR DEALER CORPORATION, INCORPORATION SERVICE ESTABLISHMENT IN THE STATE OR COUNTRY OF CONSTRUCTION FIRM OTHER (specify): OTHER (specify): TYPE OF OWNERSHIP: (check only where the contract is to be performed in the United States, its possessions and Puerto Rico) VETERAN-OWNED BUSINESS MINORITY BUSINESS ENTERPRISE (see definition below & check appropriate box) WOMEN-OWNED BUSINESS SMALL BUSINESS TOTAL SALES FOR LAST (see definition below) TWELVE MONTHS SMALL DISADVANTAGED BUSINESS YES NO (see definition below) OTHER SERVICE DISABLED VETERAN-OWNED BUSINESS INDICATE IF OWNER OR OFFICER IS ACTIVE The term "minority business" means a business concern (1) which is at least 51 percent YES NO MILITARY, U.S. GOVERNMENT EMPLOYEE, OR owned by minority group members; or in the case of any publicly owned business, at 51 RETIRED REGULAR ARMY/AIR FORCE OFFICER. percent of the stock of which is owned by one or more minority group members (2) whose INDICATE IF AN OWNER OR OFFICER IS AN management and daily business operations are controlled by one or more such minority IMMEDIATE FAMILY MEMBER OF ONE OF group members. For purposes of this definition, minority group members include YES NO ABOVE LIVING IN SAME HOUSEHOLD, AND African Americans, Hispanic Americans, Asian-Pacific Americans, PROVIDE (1) NAME, (2) RANK/GRADE, (3) RELATIONSHIP, (4) JOB TITLE, (5) and Native Americans (such as Alaskans and American ORGANIZATION/AGENCY AND (6) LOCATION. Indians, (Use separate sheet or reverse side) The term "women-owned business" means a business that is at least 51 percent owned by a If former military or Exchange employee indicate separation date: woman or women who also control and operate it. "Control" in this context means exercising the power to make policy decisions. "Operate" in this context means being actively involved in the day-to-day management. INDICATE IF AN OWNER OR OFFICER OF THE FIRM OR THE FIRM OR A RELATED FIRM HAS The term "small disadvantaged business" means a small business concern which is at least BEEN CONVICTED OF A FELONY RELATED TO 51% unconditionally owned by one or more individuals who are both socially and economically YES NO A BUSINESS TRANSACTION, OR HAS BEEN disadvantaged, or a pubically owned business that has at least 51% of its stock unconditionally SUSPENDED OR DEBARRED. owned by one or more socially or economically disadvantaged individuals. SECTION III - CERTIFICATION I certify that the information given above is correct and that owners, officers, and related firms are not now suspended or debarred by any agency of the U.S. Government. NAME AND TITLE (print or type) SIGNATURE SECTION IV - CATEGORIES OF MERCHANDISE, FOOD, SUPPLIES, EQUIPMENT, SERVICES & CONSTRUCTION Indicate on the reverse side the categories of items, services or construction that you are interested in providing to the Exchange. EXCHANGE FORM 4200-010 (REV SEP 20) (Prev Editions Obsolete) EOP 65-01 SECTION IV-A - MERCHANDISE, FOOD, SUPPLIES & EQUIPMENT List the items you wish to sell to the Exchange. You may attach a separate listing, and/or catalogs, as needed: Item Item Item SECTION IV-B - SERVICES AND CONSTRUCTION Indicate below the categories of services or construction you are interested in providing. Also indicate on an attached sheet or in the remarks section below the geographical areas/installations you are interested in serving. SERVICES 1. Customer Related Services: Tailor-Made/Made-to-Measure Barber Shops Other: (list) Optical Military Uniforms/Clothing Beauty Shops Other (list) Specialty Type Services (key- 3. Vending Services: Laundry and Dry Cleaning making, bronzing, engraving, 4. Support Services (Used by Clothing Alterations monogramming, trophies, Soft Drinks - Bottle/Can/Cup the Exchange): Optical Dispensing plaques, etc.): (list) Beer (vending machine rental Vehicle (Cars/Trucks/Trailers) Floral Service (Shop/Wire) and service only) Repair and Maintenance Sale of Handicraft/Paintings Full-Line (hot and cold cup Watch/Jewelry Repair Items: (list) MHE Repair and Maintenance beverages, juices, hot and Heating/Air Conditioning/ Shoe Repair Dental cold food, pastry, chips, Refrigeration Equipment Pet Grooming Telecommunications Services candy, cigarettes, etc.) Repair and Maintenance Custom Picture Framing Other: (list) Cigarette/Cigars Office Machine Repair and Bulk (candy, gum balls, nuts, Photographic Processing Home Delivery Service Maintenance novelties, etc.) Portrait Studio Service Station Equipment Postage Stamps Janitorial Services Pictorial Review/Yearbook 2. Food Services: Ice Security Guard Services Garage/Auto Repair Theater Refreshment Stand Prophylactics/Sanitary Armored Car/Courier Services Car/Trailer Rental Mobile Ice Cream/Sno-Cones Napkins Lockers Linen/Uniform Rental Equipment/Appliance Rental Mobile Food Service - Pizza/ Launderette (washers, dryers, Rental/Lease of Trucks/ Television Rental Fried Chicken dry cleaners, and soap and Tractor Trailers Specialty Food Service Radio/Television/Appliance bleach dispensers) MHE Rental Service Repair Facility - Pizza/Fried Chicken Pinball/Games/Pool Tables/ Bicycle/Small Motor and Refuse Collection Snack Bar - Sandwiches/ Music Machines/Scales Lawn Mower Repair Short Orders Other: (list) Living Quarters Cleaning/ Massage Chairs Lawn Care TV Chairs Miniature Golf CONSTRUCTION A. TYPE CONTRACTOR: 5. Other (specify below): B. TYPE CONSTRUCTION: C. DOLLAR VALUE: 1. General 1. New 1. Under $200,000 2. Electrical Renovation 2. Over $200,000 3. Mechanical 4. Plumbing SECTION V - REMARKS (REVERSE EXCHANGE FORM 4200-010) Page 2 SERVICES LISTINGS Automotive Service Concession Auto Detailing Stamps Stereo/Alarm Installation Other Window Tinting/Windshield Repair (Specify)____________________________ Auto Parts Store Car Care Center Health Services Quick Lube Center Audiology Other Dental Clinic (Specify)_____________________ Massage Therapy ____________________________ Optical Commodity Concession Optometry Arts and Crafts Pharmacy Book Stores Other Brass/Bronze/Pewter/Metal ware (Specify)____________________________ Candy - Boxed/Bulk Cards/Comics China/Ceramics/Pottery Services Concession Christmas/Seasonal Alterations Clothing/ Accessories/T-Shirts Appliance Repair Crystal/Glassware Barber Dolls/Toys Beauty Encyclopedia Sales Business Center Family Histories Car Rental Furniture Carnival Giftware/Collectables/Souvenirs Computer/Electronics Repair Gold/Jewelry Custom Picture Framing Leather goods Day Spa Nutrition Center Embroidery/Monogramming Service Office Supply Engraving/Trophy/Plaques Paintings/Prints/Posters Equipment & TV Rental Plaques/Trophies Equipment Repair Sports Merchandise Flower Shop Other Formal Wear Rental/Sales (Specify)____________________________ Furniture Rental Gift Wrap Services Housekeeping Vending Concession Infant Photography Amusement/Pinball/Video/Games Laundry/Dry Cleaning Bulk/Novelties Vending Locker Storage/Warehouse Bulk Water Nail Salon Car Vacuum/Car Wash Coin Operated Pack and Wrap Digital Photo Printing Pet Shop/Pet Grooming DVD/Movie Rental Photo Processing/1 Hr Photo Energy/Sport/Isotonic Drinks Portrait Studio/Painting/Sketching Full Line Vending Shoe Repair Ice Cream/Frozen Food Tailor Made Clothing Kiddie Rides Taxi/Shuttle Laundromat Truck/Trailer Rental Locker Vending T-Shirts/Personalized Clothing Newspaper Vending Unit Photography/Year Book Popcorn Vending Video Rental Prophylactic/Sanitary Napkin Watch/Jewelry Repair Recycle/Reverse Vending Other Soft Drink Vending - Bottle/Can/Cup (Specify)____________________________ Soap/Bleach Dispenser Other (Specify) EXCHANGE FORM 4200-010 (REV SEP 20) (Prev Editions Obsolete) Page 3 SERVICES LISTINGS Food Concession Services Asian Food Bagel Shop Bakery Barbecue Hamburgers/Hotdogs Candy Shop Chicken Coffee/Espresso Shop Cookie Shop Deli Shop Donuts Frozen Yogurt Ice Cream Juice/Smoothie Bar Kebab/Gyro Mobile Food Mobile Ice Cream Pizza Sandwich Snack Bar Snow Cones/Shave Ice Other (Specify)____________________________ Telecommunications Services Cable TV Service Communication Center Internet Services Long Distance Phone Services Pre-Paid/Debit Telephone Cards Satellite TV Services Telephone, Coin Operated Telephone, Residential – Local & LD Wireless – Cellular or PCS Services Other (Specify)____________________________ Support Services Bicycle Assembly/Repair Delivery Service Equipment/Merchandise Repair Janitorial Linen/Uniform Rental Printing
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